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02/14/2020
RESPONSES/COMMENTS (PM ARTICLES) - PART 1
From: Adam Zanbilowicz, DPM, MSc, BA
As we have learned that tendonitis is rarely an "itis", many of our treatment options for fascia and tendons have been shown to be ineffective. This has created a perfect opportunity for unproven therapies to be incorporated into treatment algorithms. But we must only consider these modalities as a last resort. I read Dr. Woodley's article, hoping to finally hear of a quality study that demonstrates efficacy. Sadly, the abstract of the only article referenced concludes "that the literature appears to be inconsistent and thus far, inconclusive."
This was my conclusion after reading as much primary research I could find... Many successful case studies, but higher quality studies demonstrating equivocal results. The New York Times published a wonderful article with principles of avoiding pitfalls of poor studies -- a worthwhile read: Worried About That New Medical Study? Read This First.
Adam Zanbilowicz, DPM, MSc, BA, Nanaimo, Canada
Other messages in this thread:
11/30/2023
RESPONSES/COMMENTS (PM ARTICLES) - PART 1
From: Paul Kesselman DPM
As an update on the very interesting issue of RPM and wearable technology, CMS recently had a call-in, a four hour meeting entitled Digital Technology and Diabetes. A very limited number of speakers spoke on a variety of topics, but mostly the NIH and inventors spoke about CGM (continuous glucose monitors). Some mention was made of wearable technology by some individuals from the NIH, CMS, and CDC.
Fortunately, APMA had registered me to speak at this meeting. The NIH speakers provided some time to discuss wearable technology but this was not limited to only socks and mats but also included potential use of "smart" orthotics and prosthetic devices as well as "smart" dressings. There was universal interest by these scientists who asked many questions on the impact wearables could have for reducing the significant costs our society bears in treating DM. It will be interesting to see where CMS takes this over the next few years.
Having podiatry invited to be part of the discussion with these preeminent scientists was certainly a big win and definitely shows we as a profession are part of this equation!
Paul Kesselman, DPM, Oceanside, NY
12/02/2022
RESPONSES/COMMENTS (PM ARTICLES) - PART 1
From: Josh White, DPM
I appreciate the letters written by Drs. Markinson and Kesselman regarding the article I recently wrote in Podiatry Management about why diabetic shoes aren’t prescribed more. While intended as a “How to” overcome obstacles to ensure patients are properly fit, it seems to have been perceived more as “Why not to”, get involved with footwear.
I wholeheartedly agree with Dr. Markinson’s conclusions that it’s best to have "a high-volume need", "a dedicated individual in the practice for the fitting of off-the-shelf shoes, and an available laboratory that will provide true...
Editor's note: Dr. White's extended-length letter can be read here
12/01/2022
RESPONSES/COMMENTS (PM ARTICLES) - PART 1A
From: Elliot Udell, DPM
There is an elephant in the room that we are not addressing when it comes to diabetic shoes and inserts. It’s called "entitlement." The patients feel they are entitled to them and will do anything to get them once a year, even if they do not use them. We had one patient who was "Johnny on the spot" every January 1st for his shoes. He never seemed to be wearing the old ones. When confronted, he would say that he just left them at home by mistake. Was he really using them or selling them on the street corner or on E-bay? We'll never know.
Elliot Udell, DPM, Hicksville, NY
10/05/2022
RESPONSES/COMMENTS (PM ARTICLES) - PART 1
From: Elliot Udell, DPM
Several years ago, I was given the honor at an APMA national meeting to be one of the judges of the posters that were displayed. I spent many hours reading every poster. Most were really great and showed that podiatry has the ability to merge science with medical practice. I was really proud of my profession and those that did the research. Unfortunately, there were few, if any, posters that dealt with biomechanics and foot orthotics.
Dr. Kesselman is correct. There is waning interest in that part of podiatry and it probably is a Catch-22. On one hand, it is not as lucrative as surgery and on the other hand because we are not doing the research, we don't have the ability to approach insurance companies and insist that they make it lucrative. Dr. Kesselman, I, and others can complain until the cows come home about this but we seem to be beating a dead horse. It is what it is.
Elliot Udell, DPM, Hicksville, NY
09/21/2022
RESPONSES/COMMENTS (PM ARTICLES) - PART 1B
From: William Beaton, DPM
Be careful what you ask for in payment for orthotics from insurance companies. Many of us remember when we were appropriately reimbursed for bunion/hallux valgus surgery $2,000. +/- as compared to the current reimbursement rate with the 90-day follow-up. That is what happens when insurance companies control free enterprise with participation contracts and make us providers for their insureds. This past week, I counted 19 advertisements on Facebook for all different kinds of orthotics to cure from plantar fasciitis to low back pain from $39.00 to $250.00. This is a sad state of affairs, creating confusion for the general public.
William Beaton, DPM, Saint Petersburg, FL
09/21/2022
RESPONSES/COMMENTS (PM ARTICLES) - PART 1A
From: Jeff Root
I’m glad to hear that Dr. Roth has had success with the MASS theory of foot orthotic therapy. I have spoken to other podiatrists who claim to have had success with it and others who did not experience adequate success and abandoned the MASS approach as a result. I have also spoken to podiatrists who have had tremendous success with Root’s approach and others who have had less than satisfactory results. How can one explain these contrasting experiences and outcomes? Part of the answer to that question is the fact that there is variability between and how clinicians examine a patient, cast or scan the foot, and in the devices that they order for their patients. In addition there is variability between custom foot orthotics made by different manufacturers who, in many cases, claim to subscribe to the same manufacturing theories and protocols.
Fortunately, my father Merton Root did not have a vested interest in the commercial manufacture of...
Editor's note: Jeff Root's extended-length letter can be read here.
09/15/2022
RESPONSES/COMMENTS (PM ARTICLES) - PART 1
From: Lance Malusky, DPM
That was an excellent article on including "I'm sorry!" into a conversations with a patient with an untoward result. I don't believe that PICA actually recommended that phrase, but they did recommend numerous actions to protect you from a lawsuit, and to mitigate damage to one's medical reputation. As soon as I saw an issue, such as a regrowing phenol nail, or bunion, I "followed" Dr. Baum's 4 R's. These actions were instilled by PICA's monographs and seminars over the years. As a practitioner's primary duty is the patient's welfare, recognizing a problem early and advising the patient on a course of action is necessary.
My surgical consults and permits always had a list of potential generic complications, including "death." Luckily, I could always say that never happened, and that defused the remaining scenarios as less intimidating. I always made sure that each patient, and interested family member, had a chance to read the surgical permit, which also had a blank space for specific issues with each surgical case. They would sign both copies, and retain one copy with post-op instructions sheets. (The unalterable photocopy with an original signature was the one I kept in the paper file). Hospital cases always signed at a late consult date, prior to the surgery date.
An unspoken advantage of the "Apology" discussion is the activation of the statute of limitations regarding a malpractice suit (one year in Ohio). This can be implemented in the patient chart in detail. The doctor discusses and documents the poor result, his remorse without admitting some specific "guilt,"and encourages a mutual responsibility to participate in actions for remedy. As far as monies, I would offer a redo for an occurrence less than one year post-op, but still bill insurance, and agree to write off any balances.
Lance Malusky, DPM, Dayton, OH
08/10/2021
RESPONSES/COMMENTS (PM ARTICLES) - PART 1B
From: Robert S. Schwartz, CPed
For most of the last 48 years, I’ve had the privilege of providing education and training to third year students at NYCPM. As I explain to them, the shortcut to biomechanics is the “Worn shoe evaluations, shoes-on, shoes off!” Our worn shoes tell our story. The Eneslow worn shoe evaluation form is used clinically. It’s a great tool to easily train staff and create and develop a biomechanical and forensic approach. The most efficient way to achieve this is to start assessment with patients still wearing their shoes while standing. Then, the shoes can come off for further study, along with an evaluation of the feet and body.
Disclosure: I am the President and CEO of Eneslow Pedorthic Enterprises.
Robert S. Schwartz, CPed, NY, NY
08/10/2021
RESPONSES/COMMENTS (PM ARTICLES) - PART 1A
From: Paul Kesselman, DPM
Two years ago at the APMA 2019 National, Karen Langone, Jeffery Ross, and I provided a morning session on 21st Century Biomechanics. Not more than 75 DPMs attended that session with most being over the age of 45. Few young podiatrists attended this while other surgical courses were being offered. During the intervening two years, I have posted a similar letter as Drs. Ritchie and Kirby, and have met with Dr. Shapiro, whose recent article has spurred this most recent conversation. Two years ago, rather than receiving letters of support on actions by which to resolve the issue, I received several letters from academia, defending the courses they taught at their various podiatric institutions, rather than acknowledgement that there was an issue. Several orthotic laboratories did, however, acknowledge the "problem".
Dr. Kirby's recent letter is spot on and is identical to what I was taught over 40 years ago while a student at ICPM. Unfortunately, the current students today lose much of what they are taught from the biomechanical perspective because...
Editor's note: Dr. Kesselman's extended-length letter can be read here.
08/06/2021
RESPONSES/COMMENTS (PM ARTICLES) - PART 1B
From: Richard A. Simmons, DPM
Dr. Richie, with all due respect, rather than change the topic of the question, please offer your opinion. I am simply offering my opinion. I believe medical economics and billable CPT codes are driving all aspects of medicine right now. I am 65 years old, and for the last ten years, my annual physical exam with 5 different PCPs have all occurred with me fully clothed. I’m sure the reason why is that the medical group had to crunch numbers and interpret the CPT codes, then determine that reviewing my clinical lab results and reading some snippet off of WebMD was “an annual physical exam.”
I am old enough to remember reimbursements of $300 for matrixectomies; now, it is less than half and barely more than a simple nail avulsion. I performed vascular exams for more than $200 each and simply stopped doing...
Editor's note: Dr. Simmon's extended-length letter can be read here.
08/06/2021
RESPONSES/COMMENTS (PM ARTICLES) - PART 1A
From: Jeff Pantano, DPM
One of the reasons is there isn’t (or at least I don’t know about it) a true authority/college which focuses on biomechanics and CME. You can attend one of hundreds of surgical CME meetings but not so much for biomechanics. After the classroom, maybe you get lucky and one of your residency attendings is a “biomechanical specialist”, but that’s it. I actually contacted the APMA to put together a lecture series for additional information in residency. They did do one lecture which was very nice of them. If you don’t grasp it in school, it seems like you are out of luck. I am two years into private practice and I’d benefit greatly in all aspects of my clinic with more knowledge of biomechanics. I just feel like the help isn’t there and if it is, it’s hidden.
Jeff Pantano, DPM, Milton, MA
08/05/2021
RESPONSES/COMMENTS (PM ARTICLES) - PART 1B
From: Kevin A. Kirby, DPM
Dr. Jarrod Shapiro’s recent article, “Why Are Podiatry School Graduates Not Grasping Biomechanics?” hits the nail squarely on the head. In the 36 years that I have been in private practice and teaching foot and lower extremity biomechanics, both nationally and internationally, 28 of those years involved training podiatric surgical residents on the principles of foot and lower extremity biomechanics, foot and ankle surgical biomechanics, sports medicine, and foot orthosis therapy. As Dr. Shapiro also observed, I have noted a gradual decline in the biomechanics knowledge that these third-year podiatric surgical residents possessed when rotating through my office over the past 10-15 years. As such, I believe a few comments are in order about “biomechanics”, what it means, and what we, as a profession, should do about teaching “biomechanics” to our podiatry students, podiatric surgical residents, and podiatrists.
First of all, we must all understand that the term “biomechanics” does not simply mean evaluating, casting/scanning, prescribing and...
Editor's note: Dr. Kirby's extended-length letter can be read here.
08/05/2021
RESPONSES/COMMENTS (PM ARTICLES) - PART 1A
From: Doug Richie, DPM
The post from Dr. Simmons propagates several misconceptions which are becoming pervasive in our profession about podiatric biomechanics. Biomechanics is not sports medicine. Biomechanics has been, and should continue to be, the cornerstone of all aspects of podiatric practice, particularly reconstructive foot and ankle surgery. And if "medical-economics" explains the demise of interest in biomechanics among students and practitioners, I ask Dr. Simmons to compare the reimbursement for a custom ankle-foot orthosis to any common surgical procedure we perform to correct the adult acquired flatfoot. Not only is mastery of biomechanics crucial to the selection of proper surgical intervention for this disorder, it is also fundamental to implementing a proven non-operative intervention which happens to pay the bills better than just about anything else we do in clinical practice.
Doug Richie, DPM, Long Beach, CA
10/28/2020
RESPONSES/COMMENTS (PM ARTICLES) - PART 1B
From: Bryan C. Markinson, DPM
Although I wish Dr. Levy did not invoke my name in his initial correct comments on this article, the response by Dr. Kalish has degenerated the conversation to a level that I hope to put to rest with this post. There are certain accepted and widely practiced surgical oncology principles that neither the youth of Dr. Levy or the "judgment call of the experienced surgeon" as Dr. Kalish stated, can ignore, dispute, or change.
Neither Drs. Levy, Kalish, or I are musculoskeletal oncologists, the specialty which is charged with the expertise and knowledge and research regarding the initial management of...
Editor's note: Dr. Markinson's extended-length post can be read here.
10/28/2020
RESPONSES/COMMENTS (PM ARTICLES) - PART 1A
From: Ivar E. Roth DPM, MPH, W. David Herbert DPM, JD
Kudos to Dr. Kalish. Experience trumps many clinical pathways. When you have the experience, you have wisdom that a book cannot teach you.
Ivar E. Roth DPM, MPH, Newport Beach, CA
I appreciated Dr. Kalish's comments about evidence-based medicine and experience-based medicine. This is somewhat like the arguments against anecdotal evidence and double-blind statistical study-based evidence. I have successfully convinced a jury that another name for evidence-based evidence is cookbook-based evidence and that they must completely rely on the author of the particular cookbook, who I was successfully able to discredit.
Because rules and laws regarding the evidence that can be presented to a jury in a trial vary by state, my argument would have not worked in every state. I do believe that anecdotal experiences of a very experienced surgeon can be useful in clinical situations, even though the accepted evidence-based evidence may be contrary to it.
W. David Herbert DPM, JD, Billings, MT
02/21/2020
RESPONSES/COMMENTS (PM ARTICLES) - PART 1A
From: Ty Hussain, DPM
Responding to Dr. Udell's comment about dentists having multiple sub-specialties, its point is that they are able to maintain defined specialties mainly due to one factor: how they get reimbursed vs. the rest of the medical field. I have long said that dentistry was the smartest of all medical care due to the simple fact that the majority of the patients nationwide acknowledge that dental care is a cash transaction. Yes, there is dental insurance, but the majority of the population does not carry that, and dentists for the longest time have kept themselves out of the insurance rat race to keep it a cash business.
Therefore, you can have dental specialties that can charge so much money for a procedure, knowing they will be paid upfront. Can we say that about podiatric medicine, that has strived to be like our MD colleagues and wants to be part of every insurance to get reimbursed 80% of Medicare and be content? This is what causes that podiatric surgeon who wants to only perform ankle surgeries, but due to low reimbursement, wanders into general podiatric care. Our field is based on relying on third-party payors. Changing ourselves to a cash basis is a tough hill to climb.
Ty Hussain, DPM, Evanston, IL
02/19/2020
RESPONSES/COMMENTS (PM ARTICLES) - PART 1B
From: Lawrence Oloff, DPM
I believe this dialogue about “advanced foot and ankle vs. general practice podiatrist” espoused by Dr. Sherman misses many key points. It bothers me that after all the progress that I have seen our profession make, there are still advocates that want to have our profession take two steps back. I have been involved with podiatric medical education for forty plus years and continue to do so today as a residency director. These are my observations.
Completing residency does not force its graduates to perform advanced surgery, or for that matter any surgery at all. The extent of one's practice is purely up to the discretion of each graduate of a residency program. Residency just allows its graduates to provide basic competency in the care of their patients, both as generalists and as surgeons. Finishing a residency is just the beginning of obtaining competency as a...
Editor's note: Dr. Oloff's extended-length letter can be read here
02/19/2020
RESPONSES/COMMENTS (PM ARTICLES) - PART 1A
From: Doug Richie, DPM
Regardless of what type of practitioner today's podiatric resident "wants to be", the fact of the matter is that current podiatric residency training programs do not prepare residents to manage common musculoskeletal foot and ankle problems with non-surgical interventions.
I believe this would fall under the scope of "general practice" podiatry which Dr. Sherman refers to. Dr. Jacobs uses the term "primary care podiatry" and cites the training current residents receive in the fields of rheumatology, dermatology, vascular disease, endocrinology, and neurology. How does training in these disciplines prepare the podiatric resident to evaluate and treat plantar heel pain and metatarsalgia, the two most common musculoskeletal conditions which present to the podiatric practitioner?
In this regard, Dr. Jacobs states that current residents have "excellent understanding" of biomechanics and kinesiology. If they do, this understanding came from 4 years of podiatric medical school and not from a 3-year surgical residency program. Even if this were true, training and hands-on experience in implementing non-surgical treatment of common musculoskeletal foot and ankle problems is sorely lacking in today’s podiatric surgical residency programs.
Doug Richie, DPM, Long Beach, CA
02/18/2020
RESPONSES/COMMENTS (PM ARTICLES) - PART 1A
From: Elliot Udell, DPM
Thank you, Dr. Zanbilowicz, for questioning what kind of studies should be enough to let us subject our patients to new and often expensive, out of pocket treatments. The article referenced from the New York Times is on target.
One way of determining whether a new, expensive product should get our clinical attention is whether major insurance carriers will pay for it. Peddlers of these products at medical conventions will argue with this point of view. Over the years, however, insurers such as Medicare and other major carriers will not pay for a treatment where the evidence supporting it is clinically questionable. Sometimes, when new research says that a treatment is questionable such as with ECSW therapy, Medicare stopped paying for it and dozens of shockwave providers ceased to exist.
On the other hand, if a treatment is supported by large studies from many reputable study centers and the evidence is clear that the treatment will help patients, it will not be long before insurance carriers will be forced by public outcry to pay for it. So where does this leave us? In our practice, we may offer a new treatment that may be promising if it is inexpensive and, of course, safe. On the other hand, to our own financial detriment, we will not sell a treatment that will cost the patient "a thousand dollars" or more if the preponderance of evidence does not support it.
Elliot Udell, DPM, Hicksville, NY
02/17/2020
RESPONSES/COMMENTS (PM ARTICLES) - PART 1B
From: Michael M. Rosenblatt, DPM
I read with interest the recent polls of newly graduated residents, in which the majority answered that they want to practice mostly surgery in their work. I understand this. Many years ago, I felt the same way. Because I owned my own Medicare Certified Surgical Center, there was (I suppose) a financial incentive for doing more surgery. But that is not how it turned out. The physical aspects of surgery require an enormous amount of energy that, as you age, you become less able and willing to exert. I was also a co-resident director and shared responsibility for teaching new podiatry residents surgery.
I had a surgical program at a VA hospital where I was exposed to a great deal of surgery, besides foot and ankle procedures. Even now, I am astonished at the...
Editor's note: Dr. Rosenblatt's extended-length letter can be read here.
02/17/2020
RESPONSES/COMMENTS (PM ARTICLES) - PART 1A
From: Allen Jacobs, DPM
In 40 years of working alongside podiatric residents as a residency director and mentor, never have I heard any resident tell me that primary care practice represented their first choice. Never. Particularly now when we have outstanding three-year residencies and fellowships, I have yet to meet a resident who desired non-surgical practice at the completion of such training. I have long been a strong advocate of advancing education in the non-surgical aspects of podiatry and continue to do so. However, the comments of Dr. Sherman and his alleged survey results are simply not consistent with my experience in working with residents to this day.
I should further like to point out that as a result of the excellent training which our residents now receive, most...
Editor's note: Dr. Jacobs' extended-length letter can be read here.
12/17/2019
RESPONSES/COMMENTS (PM ARTICLES) - PART 1B
From: Dale Feinberg, DPM
I took my friend aside and we did discuss how the impressions for her custom prescription orthotics were made. It was interesting to me that she retired with a degree in mechanical engineering. She stated that the podiatrist took a pronated impression in a pink foam box while the chiropractor did a full biomechanics exam including gait evaluation before using an ipad scanner and writing a custom prescription for the devices. She said she wondered why there was such a difference in completeness of her competing exams but was only interested in which orthotics felt the best, and that she now recommends all of her tennis friends to her chiropractor.
Finally, she told me her sister had a bunionectomy with perfect results done by a local podiatrist, and her best friend had a similar procedure performed by a well renowned local orthopedic surgeon with poor results. When she asked her friend why she didn’t see her sister's podiatrist, she was told the orthopedic surgeon was a medical doctor.
Dale Feinberg, DPM, Yuma, AZ
12/17/2019
RESPONSES/COMMENTS (PM ARTICLES) - PART 1A
From: Jeff Root
Dr. Udell asks, “Should we deal with any orthotic lab that is owned by podiatrists, and is actively marketing their orthotics and training to chiropractors, physical therapists, and other non-podiatric professionals?" As the owner of an orthotic lab that doesn’t market to other specialties, I believe that podiatrists should do what they believe is in the best interest of their patients, even if that means using an orthotic lab that markets to other specialties.
That said, I know of no other specialty that possesses the level and depth of education and training in non-surgical and surgical treatment of the foot and ankle and who also can provide other critical diagnostic tests and treatment such as imaging, prescription drugs, etc. While there are some individuals in other specialties who are very capable of providing good quality foot orthotic therapy, they do not possess the same range and quality of services that a podiatrist can provide. It is unfortunate that many consumers and patients do not understand the difference in the qualifications between podiatrists and other providers of foot orthotic therapy. That is why it is important to educate the public so they can determine who may be the best provider for their foot and ankle care.
Jeff Root, President, Root Lab, Inc.
10/17/2019
RESPONSES/COMMENTS (PM ARTICLES) - PART 1B
From: Ira Baum, DPM, Naples, FL
I don’t think a unified board would do anything to mitigate confusion regarding the services podiatrists provide to the public. I also think it would be a disservice to those podiatrists who received specialized training in surgery. Here’s the obvious dilemma: a majority of states require at least 2 years of post-graduate training in a certified residency program. So how can the profession satisfy state laws requiring the minimum residency training and differentiate non-surgical from surgical training?
Additionally, DPMs, by definition, are doctors of podiatric medicine and surgery, so the definition of our degree needs to be addressed. I’m sure there are many other hurdles that would need to be addressed before changes in board status, training, and meaning would be rational.
Ira Baum, DPM, Naples, FL
10/17/2019
RESPONSES/COMMENTS (PM ARTICLES) - PART 1A
From: Jeffrey M. Robbins, DPM
It is gratifying to see at least some comments on my original call for a single board. It is painfully obvious that change is hard and opinion strong on this topic. However, the future requires growth and development; otherwise it stays stagnant which will move us backward as the rest of the progressive world passes us by. We are only as good as our weakest link. Let’s make sure we have a high standard and strengthen all the links in our chain, keeping in mind that we are a procedure-based profession regardless of the simplicity or complexity of those procedures.
Jeffrey M. Robbins, DPM, Cleveland, OH
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